Chapter 26: Nursing Assessment: Respiratory System

Chapter 26: Nursing Assessment: Respiratory System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
1. A patient with acute shortness of breath is admitted to the hospital. Which action should
the nurse take during the initial assessment of the patient?
a. Complete a full physical examination to determine the systemic effect of the
respiratory distress.
b. Obtain a comprehensive health history to determine the extent of any prior
respiratory problems.
c. Delay the physical assessment and ask family members about any history of
respiratory problems.
d. Perform a respiratory system assessment and ask specific questions about this
episode of respiratory distress.
ANS: D
When a patient has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later. Obtaining a
comprehensive health history or full physical examination is unnecessary until the acute
distress has resolved. A focused physical assessment should be done rapidly to help
determine the cause of the distress and suggest treatment. Although family members may
know about the patient’s history of medical problems, the patient is the best informant for
these data.
DIF: Cognitive Level: Application REF: 504
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. When preparing the patient with a right-sided pleural effusion for a thoracentesis, how
will the nurse position the patient?
a. Supine with the head of the bed elevated 45 degrees
b. In the Trendelenburg position with both arms extended
c. On the left side with the right arm extended above the head
d. Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to
collect at the lung bases, and expands the intercostal space so that access to the pleural
space is easier. The other positions would increase the work of breathing for the patient
and make it more difficult for the health care provider performing the thoracentesis.
DIF: Cognitive Level: Comprehension REF: 516
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Test Bank 26-2
3. A patient is admitted with a metabolic acidosis of unknown origin. Based on this
diagnosis, the nurse would expect the patient to have
a. intercostal retractions.
b. Kussmaul respirations.
c. a low oxygen saturation (SpO2).
d. a decrease in venous O2 pressure.
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic
acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PvO2
would not be caused by acidosis.
DIF: Cognitive Level: Application REF: 511
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds during
exhalation in the lower 1/3 of both lungs. The nurse records this finding as
a. expiratory crackles at the bases.
b. expiratory wheezes in both lungs.
c. abnormal lung sounds in the bases of both lungs.
d. pleural friction rub in the right and left lower lobes.
ANS: B
Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase
of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovesicular
sounds heard in the peripheral lung fields. Crackles are low-pitched, “bubbling” sounds.
Pleural friction rubs are grating sounds that are usually heard during both inspiration and
expiration.
DIF: Cognitive Level: Comprehension REF: 511
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity